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JL <br /> IN <br /> o -~San Joaquin County <br /> Envinmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9� MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov CE�VEDUNIT IV <br /> P Well Permit Appiication JAN 0 7 7005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> nty for a permit to construct and/or install the work des <br /> QN ,14j&iET"de in compliance with San <br /> Application is hereby made to San Joaquin Cou �nkrAent. <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environ � R Assessors <br /> WELL Location 23-45 4. Cross Street r City m Zip-7•02'9-_Parcel#_ � <br /> PROPERTYu,jar` ryr`�4xPfer'�5 , <br /> Owner S keit b rvc#k Address`l�� city Z,i 7�o _Phone# Z <br /> Z 6 R � <br /> C-57 Contractor ddress City Zip Lic#`�Phone <br /> Consultant!Sub Cntr <br /> Ceavb L. r•v;�n Ad ress z > 'iY[cik5 3T'_CitY�- <br /> • Lic# Phone# � 3 2- 7�2. <br /> GIS Coordinates:X ,y_,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL 1 BORING CQ ,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> IVT'_ a SOIL BORING# <1 PR <br /> — _ 0EDIAMETER <br /> Q WELL# [}PRESSSURSOR E.E GROUT <br /> [ *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE �i� MULTIPLE CASINGS H MULTI-LEVEL WELL CASING DIA: r <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS `" TYPE OF CASING: 0 STEEL 1]PVC p OTHER: <br /> 0 VAPOR it MUD ROTARY DEPTH OF GROUT SEAL - TREMIE TYPE TO BE USED: 1]AUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE PUSH POINT(GP or OGROUT SEAL PUMPED: Xyes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_- }'ki►1� `�c tia " <br /> p OTHER: p OTHER APPROX.BORING DEPTH es— 1]BOLTED TRAFFIC BOX or d STOVE PIPE <br /> r CONDUCTOR CASING PROPOSED_ (if YES,list specifications in comment section) <br /> COMMENTS: <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin <br /> I� County Ordinances, Rules and Regulations, and all applicable California State Laws. _ <br /> 4 Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> J <br /> Application Accepted By Date Issued 1 cov —Area <br /> V IV <br /> Grout Inspection By Date Final Inspection By. Date <br /> Destruction Inspection By pate <br /> i COMMENTS/CONDITIONS: s h - 7 f } <br /> ACCOUNTING ONLY; AID# FAC# ! � � <br /> l PE CODES FEEINFO AMOUNT REMITTED CHEGK# REC'O By DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 so <br /> sq . d o 2-00 S &4SR# 4�a <br /> C-57 WC -WAIVER C-57 Letter of Autho za on o sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />